Monday, September 27, 2010

Medical Emergency---a Friend’s Experience

A couple of weeks ago we received a call from a friend telling us that his wife had not felt well all day and had just vomited what looked like blood. Since Collie is a nurse, he wanted to know if they should go to the hospital, or wait until morning. Collie advised immediate evaluation at our local hospital’s emergency room.

When they arrived at the hospital her blood pressure was only 84/54 and she was looking “pretty ashen”. The triage nurse assured them she would be seen by the MD immediately. Since they are not yet members of the national health care insurance system (CAJA), he used her passport number to register her which only took minutes to collect her name, passport number, phone number, and place of residence.

In less than 5 minutes she was evaluated by the MD who immediately admitted her for observation, intravenous fluids, lab work, and nasogastric tube to monitor for continued bleeding. The plan was to have the gastroenterologist perform a diagnostic endoscope in the morning, unless the bleeding did not stop. Then an emergency scoping would be done.

Upon returning from completing the admitting paperwork, our friend had some challenges in finding out what was going on with her. Fortunately the patient is fluent in Spanish, so when finally he was able to see her, she was able to tell her husband what the plan was. She already looked much better after getting some IV fluids on board. They had explained to her that continued bleeding might require transfusion (s). That wasn’t necessary. They were also prepared to send her to San Jose if a different level of care was required.

He went home and returned to the hospital the next morning. Some other friends met him there. Trying to find out where she was was challenging. After checking various stations one “tough nurse shook the facts loose” and found her right where she was the night before in the observation area. They were advised that they couldn't see her because she was getting a test done and to come back in about 1 hour. Upon their return a new receptionist was on duty and told them that visiting hours were over. Their friend had to “strong arm the receptionist” to let him get in to see her. She looked much better, was still on saline drip, nasogastric tube gone since the bleeding stopped during the night; and she was waiting to get the scope done. She had a shower and was feeling better. No timetable for the scope, just "soon".

The gastroenterologist scoped her about 11 AM and found erosive gastritis and the bleeding had already stopped. She was deemed ready for discharge with prescriptions for a proton pump inhibitor and antacids and advice to decrease acidic foods and return for lab work.

Then they tried to pay the bill. Apparently there isn’t a system of a charge slip detailing the procedure codes and supplies which can be then compared to a charge master sheet to compile a bill. No one seemed to know what to charge. They experienced a “run around” during which they were shuffled back and forth. Finally they just had to tell the cashier which services were received, who still didn’t know what to charge. At last (about an hour later) the supervisor arrived and upon hearing the services told the cashier that the “private pay” charges would be 103,000 colones (Approximately $200). This bill included the emergency MD evaluation, overnight in the observation area, IVs, three prescriptions, Gastroenterologist evaluation and gastroscope procedure, lab work including the follow-up labs. Their friend suggested that it is common with private pay patients to just leave, let the hospital sort out the bill, and they will call you by phone to come pay the bill later. But they decided to stay and take care of it. They had to wait for the prescriptions anyway which was about a 2 hour wait at the CAJA pharmacy. So, shortly after getting the hospital bill paid, they were able to pick up the meds and head home.

In summary, she was well cared for without any delay. The treatment was appropriate for a medical emergency. She was stabilized, observed, and had a diagnostic procedure. She is getting follow-up care this week, which is likely to include some additional diagnostics. What I find to be different is the level of communication. It is probably more like medicine was years ago in the USA; the MD just told people what was wrong and what the treatment was. There wasn’t much if any dialogue about options for treatment or the patient’s wishes. Here explanations are not offered, but upon questioning, information is forthcoming. I don’t think the culture is as demanding of the medical staff as we are in the USA. The concept of partnership between a patient and physician has not entered the consciousness of the culture.

The lack of well defined systems and a customer service culture were only evident after the emergency was over. The actual wait times and customer service levels vary greatly across the system. We’ve heard of ridiculous wait times for screening procedures at some facilities, yet here in San Ramon wait times are about what I’ve experienced in the states or in some cases remarkably less. One of my friends here feels that the service provided by the CAJA isn’t much different from what she (she is a RN also) experienced in the Seattle area. I have nearly always worked for organizations that excel at customer service and provide high quality care, so I have high standards. The system here isn’t perfect. We have the option of seeking care or second opinions outside of the system for which we would pay out of pocket. The CAJA costs about $45/month for two of us. That includes everything without any co-pays. There is no way we could have retired early and stayed in the US. Even with a subsidized retiree medical through my former employer, the cost would have been prohibitive.

Saturday, September 25, 2010

Almost 12 Feet so Far

We're in the middle of an especially wet “Green Season”. This month, we’ve had several days with over 4” of rain in 24 hrs. The road system is taking a real beating with numerous road washouts and bridge closures throughout the country. So far this month, we’ve had 30.77 inches of rain, bringing the total for the year to 141 inches (11 ft, 9 inches)

Click on this link for a video of one example of of last week’s road damage posted by Fernando Obando.